Skin cancer prevention: A blue chip investment in health

Transcription

1 Skin cancer prevention: A blue chip investment in health Cancer Council Australia & The Australasian College of Dermatologists February 2009 Contact: Craig Sinclair Chair, National Skin Cancer Committee Cancer Council Australia Craig.Sinclair@cancervic.org.au Ph:

2 Table of contents A RATIONALE FOR FURTHER INVESTMENT IN SKIN CANCER PREVENTION CAMPAIGNS... 3 Introduction... 3 Size and dimension of the problem... 5 Skin cancer in Australia at a glance... 6 EVIDENCE SUPPORTING A NATIONAL SKIN CANCER PREVENTION PROGRAM.. 7 Skin cancer prevention programs in Australia Evidence for effect on knowledge, attitudes and beliefs Evidence for effect on behaviours Evidence for effect on sunburn Evidence for effect on trends in incidence of skin cancer Requested budget Cancer Council contribution APPENDIX A ADVERTISEMENT IMAGES FROM THE NATIONAL SKIN CANCER AWARENESS CAMPAIGN REFERENCES... 20

3 A RATIONALE FOR FURTHER INVESTMENT IN SKIN CANCER PREVENTION CAMPAIGNS Introduction Skin cancer is an enormous health problem in Australia. It causes around 1,600 deaths each year and costs the health system more to treat than any other form of cancer. Yet almost all cases are preventable, through appropriate protection from ultraviolet radiation. The good news is we have evidence that shows how public health programs can encourage SunSmart behaviour that will save lives, reduce morbidity and generate major health system costs savings. As Australia prepares for an unprecedented rise in cancer cases due to population ageing alone (as well as the other systemic challenges of demographic change), now, more than ever, government needs to invest in measures that will ease pressure on an increasingly strained health system. Prevention is the key. Evidence from SunSmart (as well as other public health programs, such as the National Tobacco Campaign) highlight that health promotion programs with a mix of strategies built around social marketing are fundamental to effecting behaviour changes that improve health outcomes. There is clear evidence that investment in social marketing to encourage SunSmart behaviour can significantly reduce the social and economic costs of skin cancer. 1 If social marketing investment declines, so does people s sun protective behaviour. This evidence supports that further action by government is required to prevent avoidable skin cancer and related deaths. The data highlights that sustained investment is important, because when campaign activity decreases so too can the rate of change towards sun protection. 1 Epidemiological data is also presented in this paper, as is a summary of the compelling economic evidence for This evidence supports further action to return on investment. prevent avoidable skin cancer and related deaths. This evidence supports the need for an ongoing national SunSmart program. To fund this program, Cancer Council Australia is requesting support from the Australian Government, in the amount of at least $8.3 million per annum for a period of five years, for a comprehensive national SunSmart program. This investment will provide the Australian Government excellent value for money. 3

4 This paper outlines the evidence to support the continuation of skin cancer prevention programs in Australia particularly an Australian Government commitment to an ongoing national skin cancer awareness campaign. The detailed economic analysis underpinning the recommendations in this summary report is available in a separate, report prepared by Deakin University. 4

5 Size and dimension of the problem At least two in three Australians will be diagnosed with skin cancer before the age of 70: it is the most common cancer in Australia. 2 Australians are four times more likely to develop a skin cancer than any other form of cancer. 3 This high prevalence results in over 1,600 Australians dying from skin cancer each year. 4 Most of these deaths are from melanoma, the incidence and At least two in three Australians will be diagnosed with skin cancer in their lifetime. mortality of which is shown in Figure 1. The burden of this disease among Australians living in rural, regional and remote populations is even greater than in major cities. Indeed 60% of new cases of cancer outside major cities are due to melanoma. 5 Age-standardised rate per 100,000 (World Standard Population) Male incidence Female incidence Male mortality Female mortality Year of diagnosis / death Figure 1: Melanoma incidence and mortality; Australia The magnitude of this disease places great demand on healthcare resources. More than 380,000 Australians are treated for skin cancer each year 3,6 : that equates to over 1,000 people every day. In Australia general practitioners (GPs) have almost one million patient encounters every Skin cancer is the most expensive cancer in Australia. In excess of $294 million is spent annually. year for skin cancer. 7 The economic impact of this is significant. Skin cancer is the most expensive cancer in Australia. In excess of $294 million is spent annually on the diagnosis and treatment of skin cancers: non-melanoma skin cancer ($264 million) and melanoma ($30 million). 8 Economic losses go beyond diagnosis and treatment, with significant production losses also impacting Australian society. 9 5

6 Skin cancer in Australia at a glance Over 1,600 Australians die from skin cancer each year. 4 At least 2 in 3 Australians will be diagnosed with skin cancer before the age of Sun exposure has been identified as the cause of around 99% of non-melanoma skin cancers and 95% of melanoma in Australia. 10,11 Over 380,000 Australians are treated for skin cancer each year 3 : that s over 1,000 people every day. In 2002, skin cancers accounted for over 80% of all cancers diagnosed in Australia. 3 Skin cancer costs the health system around $300 million annually, the highest cost of all cancers. 8 Each year, Australians are four times more likely to develop a common skin cancer than any other form of cancer. 3 GPs in Australia have nearly one million patient encounters per year for skin cancer. 7 It has been estimated that regular use of sunscreen during the first 18 years of life could reduce the incidence of non-melanoma skin cancer by around 60%. 12,13 1,900 premature deaths will be prevented by the SunSmart program over the next 20 years. 9 SunSmart programs have the potential to reduce the number of cases of melanoma by 20,000 and NMSC by 49,0000 over the next 20 years (based on the success of SunSmart programs since 1998). 9 The program is extremely cost-effective with a $2.32 net saving for every dollar spent. 9 6

7 EVIDENCE SUPPORTING A NATIONAL SKIN CANCER PREVENTION PROGRAM 232% return on investment over 20 years A rigorous cost-benefit analysis by Melbourne s Deakin University shows that investment in a national SunSmart program to prevent skin cancer would return $2.32 to government for every $1 invested. The detailed analysis, including methodology and discussion, is available in a separate report. The researchers applied a number of models and used conservative figures for their analysis. The 232% return on investment is based on an optimal outlay of 28 cents per capita each year over 20 years, which, on the basis of the effectiveness of the Australian Government s current SunSmart program (see following), would prevent 80,000 melanoma and 111,000 NMSC cases, when compared with a national SunSmart program running at a lower level of investment of 7c per capita (a figure based on the lower SunSmart investment in some jurisdictions). In terms of incidence and mortality, the analysis shows that, based on the success of SunSmart programs since 1988, an ongoing commitment to a national SunSmart program over the next 20 years would result in 20,000 fewer melanoma cases and 49,000 fewer NMSC cases. Using the same framework, An ongoing national SunSmart program would a SunSmart program would prevent 1,900 premature provide strong value for deaths over the same period. money, not only from a health sector perspective, but also from a broader societal perspective. Further extrapolation of historical data from the effectiveness of SunSmart programs indicates that 341,000 years of life would be lost to melanoma in Australia over the next 20 years if the per capita investment was limited to 7c per capita. Increasing this investment to 28c per capita would reduce years of life lost to melanoma deaths to 250,000 over the same period a net reduction of 91,000 years of life lost over the period In today s money, this equates to an annual commitment of around $8 million. This would deliver savings to government through reduced healthcare costs of more 7

8 than $266 million over 20 years. The economic analysis also shows the investment would generate net production gains in the general economy of around $90 million. A total of 122,000 disability adjusted life years (DALYs), including years of life lost (YLL) and years lived with disability (YLD), would be averted the majority (73,000 DALYs) from health gains in melanoma prevention. In the sensitivity analysis documented in the economic report, the intervention remains compellingly cost-effective even if the demonstrated effectiveness of SunSmart programs is reduced by 50%. Health system gains based on the level of effectiveness achieved by the SunSmart program since 1988: - 20,000 fewer melanoma cases over the next 20 years - 49,000 fewer NMSC cases in the next 20 years - A reduction of 1,900 premature deaths - For every $1 invested, $2.32 returned This represents strong value for money. (Shih & Carter 2008, unpublished) A recent study compared production gains/losses of many major preventive health interventions and this also highlights the cost-effectiveness of the SunSmart program. 25 The losses and gains examined include absence from paid work due to premature death or retirement and/or short-term absences from paid work due to ill-health. The SunSmart program scored a very high ranking of 2, out of the 21 interventions being reviewed (see Table 2, over page). 8

9 Risk factor Intervention Ranking before production gains Ranking after production gains CVD risk factors Community Heart Health Program 1 1 UV exposure SunSmart program 2 2 Smoking Call back counselling 2 3 Alcohol use Brief GP intervention 4 8 Depression Depression Maintenance CBT for five years with public psychologist Maintenance CBT for five years with private psychiatrist Smoking Buproprion 7 7 CVD risk factors Beta blockers targeted at 15% risk group 8 11 Smoking Nicotine replacement therapy 9 9 CVD risk factors Dietary counselling targeted at 10% risk group Alcohol use Random breath testing 11 4 Cervical Cancer Screening (current practice) Physical Inactivity Active GP script Depression Maintenance SSRIs for 5 years CVD risk factors CVD risk factors Dietary counselling targeted at 5% risk group ACE inhibitors targeted at 10% risk group CVD risk factors Beta blockers targeted at 5% risk group CVD risk factors ACE inhibitors targeted at 5% risk group CVD risk factors Combination targeted at 15% risk group Physical inactivity Exercise physiologist Depression Opportunistic screening + CBT Table 2: Comparative ranking of interventions on cost-effectiveness ratios before and after inclusion of production gains 25 9

10 Skin cancer prevention programs in Australia Since the early 1980s skin cancer prevention programs have operated in all Australian state and territory jurisdictions, mostly under the brand of SunSmart. Exposure to UV (mostly sunlight) causes around 99% of non-melanoma skin cancers (NMSC) and 95% of melanoma cases in Australia. 10,11 Therefore, skin cancer prevention has focused on motivating people to adopt sun protection behaviours and advocating for environmental and legislative change. There has been considerable variance, year to year, in investment on such skin cancer prevention programs; they have often operated below optimal levels for a comprehensive campaign. 9 In the Australian Government funded the first national mass media campaign on skin cancer awareness, with approximately $6 million. 9 This consisted of television, print and radio advertisements aimed at educating Australians about the importance of protecting themselves from skin Currently there is no cancer (see Appendix 1). The national campaign was commitment to ongoing extended in January 2008 for one additional year. funding, yet there is a body of evidence that This phase of the campaign focused on the risks points to the effectiveness of broadbased sustained associated with cumulative sun exposure. It also aimed to increase awareness among young Australians programs. of the seriousness of skin cancer, and promoted multiple sun protection behaviours as normal and socially acceptable (see There is now a solid body of evidence collected by Cancer Council Australia that points to the effectiveness of both the previous national campaign, as well as other state-wide, broad-based sustained programs. A summary of this evidence is outlined in the following sections. 10

11 Evidence for effect on knowledge, attitudes and beliefs A survey conducted in the middle of the first National Skin Cancer Awareness Campaign, during summer of , involved interviews with 652 adolescents (12 17 years) and 5085 adults (18 69 years). This research identified that awareness of the campaign message was generally high. It also A study conducted in the middle of the first National showed significant improvements in Australians Skin Cancer Awareness skin cancer prevention attitudes and beliefs since Campaign showed improvements in the previous survey, conducted in prior to Australians skin cancer prevention attitudes and the Australian Government s national skin cancer beliefs. campaign. 14 In particular there were significant improvements in the number of people who no longer desired a tan and most importantly a reduction in the number of adults who reported getting sunburnt. 15 The national campaign reached a large cross section of the population with 64% of adolescents and 58% of adults able to recall the campaign television advertisement. Notably, the highest level of campaign awareness was among adults with sensitive skin and among younger adults. For example 93% of adolescents who had seen the Australian government campaign advertisements could also recall at least one of the key messages. Thirty-five percent of adults and 44% of adolescents who reported seeing the advertisement were able to recall its main slogan protect yourself from the sun in five ways: with a hat, clothing, shade, sunglasses, and sunscreen. 14 Most respondents reported the advertisement would make them think about what Most respondents reported the advertisement would encourage them to protect their skin. it would be like to get skin cancer in the future, as well as encourage them to protect their skin. Importantly, compared to the previous national survey conducted in , there were increased beliefs among both adolescents and adults that skin cancer could be avoided with regular sun protection. There was also a decrease in desire for a suntan (see Table 1)

12 (n=5073) (n=5085) Adjusted Odds Ratios p-value *<.05, **<.01, ***p<.001 Like to get a tan Yes 39% 32% 0.73*** Attempted a suntan this season Yes 15% 11% 0.67*** Table 1: Adults desire for a suntan and intentional tanning decreased 31 12

13 Evidence for effect on behaviours Most of the evidence relating to behaviour change associated with skin cancer prevention messages comes from Victoria, where the SunSmart program has been in place for many years. Regular population surveys by The Cancer Council Victoria show that campaign messages have impacted on behaviour through changes such as improved sunscreen and hat wearing during outdoor activity. 1,16 Messages have reached A recent Victorian study also showed significant gains many Australians and in sun protection behaviour, which coincide with the have impacted on their behaviour. ongoing conduct of the SunSmart skin cancer prevention campaign. This study involved observing teenagers and adults to determine their sun protection behaviour while they were engaged in outdoor leisure activities on summer weekends. Data collected over more than a decade showed significant improvements in people s use of sun protective clothing over time. 17 Further analysis of the Victorian data examined whether trends in behavioural risk factors for skin cancer over a 15-year period (1987 to 2002) were associated with the extent of SunSmart television advertising. This identified that sun protection behaviours changed over time in concert with fluctuations in the amount of television advertising broadcast. So where survey participants were exposed to Sun protection behaviours changed over time in concert with fluctuations in the amount of television advertising broadcast. higher levels of SunSmart advertising in the four weeks before being interviewed, there was an increase in their preference for no tan, hat and sunscreen use, and the proportion of body surface they protected from the sun (see Figure 2). These data highlight that sun protective behaviours are amenable to change. A population s behaviours and attitudes toward sun protection can improve or decline in response to prevailing influences; this underlines the value of long-term commitment and adequate resources for population-based skin cancer prevention programs, that include televised media campaigns and strategies to monitor and evaluate outcomes. 1 13

14 .7.6 Hat cover Sunscreen* Body exposure index**.5 Probability Cumulative TARPS - previous 4 weeks Figure 2: Effect of TARPS on sun protection behaviour 1 Evidence for effect on sunburn Sunburn has been linked to increased melanoma risk, 10,18 and UVA and UVB exposure from the sun and sun tanning equipment is the only recognised modifiable risk factor for melanoma. 19 As melanoma outcomes produced from behaviour change due to prevention programs are often not available in the timeframe during which most programs are evaluated, sunburn incidence is commonly used as a proxy indicator to assess skin cancer prevention programs. 20 Analysis of nine crosssectional surveys conducted between 1987 and 2002 showed a significant reduction in sunburn incidence across most survey years when the SunSmart program was being implemented, compared with the pre-sunsmart baseline. 1 14

15 Evidence for effect on trends in incidence of skin cancer National data on incidence of treated non-melanoma skin cancer in 2002 shows there was more than five times the incidence of all other cancers combined. Although overall non-melanoma skin cancer rates have risen since 1985, rates have stabilised for people younger than 60 years, who were exposed to skin cancer prevention programs in their youth. This highlights the importance of maintaining and strengthening these programs and the influence of prevention campaigns. 2 Melanoma incidence in Australia continued to rise between 1982 and 2004, due in part to increased early detection of lesions. However, NMSC rates have there is a slower increase than previously among those stabilised for people younger than 60 years, aged over 50 years, and falling incidence rates in men who were exposed to skin cancer prevention and women younger than 40 years. These falling rates programs in their youth. in younger age groups (who grew up with the SunSmart message) in a context of increased incidence overall, are consistent with a positive effect of the SunSmart program (see Figure 3). 21 There is also a decline in melanoma mortality in younger age groups. 22,23 Better treatment and long-term survival rates have been achieved through earlier detection of skin cancer

16 FEMALE 300 Age-specific incidence per 100, Median year of birth MALE Age-specific incidence per 100, Median year of birth Figure 3: Melanoma incidence trends by age group and sex, Australia,

17 WHERE TO FROM HERE? It is clear that skin cancer prevention messages are reaching and influencing the behaviours of many Australians. Yet new audiences are constantly emerging, such as new parents, new school students and new immigrants, and it is important that the messages reach these people. 26 There is also the need to continue to evolve skin cancer prevention efforts to address new evidence and other messages in the media, for example regarding the effect of decreased sun exposure on vitamin D production. 27,28 It is important to continue to monitor community understanding of the risks and benefits of sun exposure, both in order to ensure that the SunSmart messages are appropriately delivered for groups at higher risk of vitamin D deficiency than of skin cancer, and to ensure that the vitamin D issue is not used as a justification for those at higher risk of skin cancer to increase their summer sun exposure. Some recent trends in popular media may be counter-productive to the SunSmart message. For example, content analysis of summer issues of popular women s magazines from 1987 to 2005 revealed that the proportion of models depicted wearing hats decreased, and the proportion of models portrayed with moderate to dark tans declined then later increased. 29 If we are to maintain momentum in promoting SunSmart knowledge, attitudes and behaviour in the population, evidence suggests a strong media presence for the SunSmart campaign is essential, else the skin cancer prevention message may be dwarfed by contradictory media content. While gains have been made in attitudes and sun protection behaviour change, health promotion efforts must be strengthened. Only efforts that are ongoing will produce the sustainable change that is greatly needed. If investment in skin cancer prevention is not Only efforts that are ongoing will produce maintained, the evidence is clear that there will be a the sustainable change that is regression in sun protective behaviour and millions of urgently needed. dollars of public health investment will be lost

18 Requested budget Skin cancers and related costs can be significantly reduced with ongoing funding of $8.3 million per annum for five years. The request of $7 million per annum for social marketing is reflective of original government budget investments in this area. Hence the request is for this initial amount to be maintained in value on an on-going basis. This would enable a comprehensive national SunSmart program. In addition to this we need to improve monitoring as outlined in the budget below: 1 Social marketing media campaign $7 million 2 Promotional activities in schools and workplaces $1 million TOTAL PER ANNUM $8 MILLION 3 National Monitoring Incidence of Non-Melanoma Skin $500,000 Cancer (every 5 years) 4 National Sun Protection Survey (every 3 years) $300,000 The evidence is clear that a sustained skin cancer prevention program will not only save many lives, but provide a positive return on investment. Cancer Council contribution State and territory Cancer Councils have a 20-year history in delivering skin cancer social marketing campaigns, but have difficulty in sustaining investment in paid advertising. For this reason, efforts by the Cancer Councils are generally directed to community engagement and below the line social marketing activity that targets schools, early childhood settings, workplaces, local governments and sport and recreation settings. As a conservative estimate, Cancer Councils contribute over $3 million per year to skin cancer prevention activity and will continue to provide valuable support to future Australian government campaigns. Unlike other preventive causes of ill-health, we have clear evidence to know how to reduce the enormous human and financial burden of skin cancer; the evidence highlights that a sustained national SunSmart program is critical to address the problem. Turning this knowledge into action is vital and funding at the level requested will enable us to make a significant impact on the human cost of skin cancer in this country. 18

19 APPENDIX A ADVERTISEMENT IMAGES FROM THE NATIONAL SKIN CANCER AWARENESS CAMPAIGN Surgeon, Professor Thompson Real life 22-year-old melanoma patient Surgeon operating on a mole The five ways to protect yourself message 19

20 REFERENCES 1. Dobbinson SJ, Wakefield MA, Jamsen KM, Herd NL, Spittal MJ, Lipscomb JE, Hill DJ. Weekend sun protection and sunburn in Australia: Trends ( ) and association with SunSmart television advertising. American Journal of Preventive Medicine 2008; 34: Staples M, Elwood M, Burton R, Williams J, Marks R, Giles G. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since Medical Journal of Australia 2006; 184: Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR). Cancer in Australia: an overview, Cancer Series Number 37. Canberra: AIHW, Australian Institute of Health and Welfare. State & territories GRIM (General Record of Incidence of Mortality) Books. Canberra: AIHW, Australian Institute of Health and Welfare (AIHW). Rural, regional and remote health: indicators of health status and determinants of health. Rural Health Series no. 9. Canberra: AIHW, National Cancer Control Initiative. The 2002 national non-melanoma skin cancer survey. A report by the NCCI Non-melanoma Skin Cancer Working Group. Edited by M. P. Staples. Melbourne: NCCI, Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR). Cancer in Australia Cancer Series Number 28. Canberra: AIHW, Australian Institute of Health and Welfare. Health system expenditures on cancer and other neoplasms in Australia, Health and Welfare Expenditure Series Number 22. Canberra: AIHW, Shih S, Carter R. Economic evaluation of a national SunSmart program (unpublished). Melbourne: School of Health and Social Development, Deakin University, Armstrong BK. How sun exposure causes skin cancer: an epidemiological perspective. In: Hill D, Elwood JM, English DR, eds. Prevention of Skin Cancer. Dordrecht, the Netherlands: Kluwer Academic Publishers, 2004, pp Armstrong BK, Kricker A. How much melanoma is caused by sun exposure? Melanoma Research 1993; 3: Godar DE, Urbach F, Gasparro FP, van der Leun JC. UV doses of young adults. Photochemistry & Photobiology 2003; 77: Stern RS. Proportion of lifetime UV dose received by age 18, what Stern et al actually said in Journal of Investigative Dermatology 2005; 124: Dobbinson S, Jamsen KM, Francis K, Dunlop S, Wakefield MA National Sun Protection Survey Report 1. Skin cancer prevention knowledge, attitudes and beliefs among Australians in summer and comparison with in the context of the first national mass media campaign. Prepared for the Australian Government Department of Health and Ageing, and The Cancer Council Australia in consultation with a national collaborative research group. Melbourne: Centre for Behavioural Research in Cancer, The Cancer Council Victoria, unpublished Dobbinson S, Jamsen KM, Francis K, Wakefield MA National Sun Protection Survey Report 2. Australians sun protective behaviours and sunburn incidence on summer weekends, and comparison with in the context of the first national mass media campaign. Prepared for the Australian Government Department of Health and Ageing, and The 20

21 Cancer Council Australia in consultation with a national collaborative research group. Melbourne: Centre for Behavioural Research in Cancer, The Cancer Council Victoria, unpublished Hill D, White V, Marks R, Theobald T, Borland R, Roy C. Melanoma prevention: behavioral and nonbehavioral factors in sunburn among an Australian urban population. Preventive Medicine 1992; 21: Dixon HG, Lagerlund M, Spittal MJ, Hill DJ, Dobbinson SJ, Wakefield MA. Use of sun-protective clothing at outdoor leisure settings from 1992 to 2002: Serial cross-sectional observation survey. Cancer Epidemiology, Biomarkers & Prevention 2008; 17: Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes & Control 2001; 12: Burton R, Elwood M, Makin JK, Sinclair CA. Prevention and screening. In: Balch C, Houghton AN, Sober AG, Soong SJ, Atkins MB, Thompson JF, eds. Cutaneous Melanoma. (5th edn). St Louis: Quality Medical Publishing, in press. 20. Hill D, White V, Marks R, Borland R. Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma. European Journal of Cancer Prevention 1993; 2: Thursfield V, Giles G. Canstat No. 44: Skin cancer. Melbourne: The Cancer Council Victoria, Giles GG, Armstrong BK, Burton RC, Staples MP, Thursfield VJ. Has mortality from melanoma stopped rising in Australia?: Analysis of trends between 1931 and British Medical Journal 1996; 312: Giles G, Thursfield V. Trends in skin cancer in Australia. Cancer Forum 1996; Special Edition: Thursfield V, Giles G, Staples MP. Skin cancer. Melbourne: The Anti-Cancer Council of Victoria, Magnus A, Mihalopoulos C, Carter R. Department of Treasury and Finance evaluation of preventive health interventions (unpublished) Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and SunSmart, : Skin cancer control and 20 years of population-based campaigning. Health Education & Behavior 2001; 28: Hill D, Marks R. Health promotion programs for melanoma prevention: screw or spring? Archives of Dermatology 2008; 144: Scully M, Wakefield M, Dixon H. Trends in news coverage about skin cancer prevention, : increasingly mixed messages for the public. In: 9th Biennial Behavioural Research in Cancer Control Conference. Melbourne, Dixon H, Dobbinson S, Wakefield M, Jamsen K, McLeod K. Portrayal of tanning, clothing fashion and shade use in Australian women's magazines, Health Education Research Australian Institute of Health and Welfare (AIHW). Australian Cancer Incidence and Mortality Books (ACIM). Canberra: AIHW, Dobbinson, S, Jamsen K, Francis K, Dunlop S, Wakefield M. Monitoring changes in Australians skin cancer prevention behaviours: Findings of the National Sun Protection Survey. 9th Behavioural Research in Cancer Control Conference; Melbourne, 9-11 April